护理记录书写中存在的问题及对策

目的了解护理记录书写中存在的问题,并提出相对应的对策。方法以《广东省病历书写规范》为标准对本院1300份入院和出院病历进行质量检查,找出护理记录书写存在的问题。结果1300份入院和出院病历存在护理缺陷的病历的有433份。护理记录书写存在的问题分别为记录治疗性措施多(91.9%),护理记录字迹不清、涂改(82.2%),病情描述含糊不清(59.6%),记录不及时(43.6%)和医护记录不一致(28.6%)。结论转变观念,加强医护间的密切配合,实施临床护士层级管理和设计护理记录表格对提高护理记录书写质量具有重要的意义。

Objective To investigate the problems in writing nursing reports and propose pertinent countermeasures. Method 940 discharge histories and 360 hospitalization histories were checked in line with Guangdong Province Patient＇s History Writing Criteria, in order to find out the problems in nursing reports. Result 433 histories were found with problems in nursing reports writing, including too many descriptions on therapeutic measures （91.9%）, blurring and correction in nursing records （82.2%）, abstract description of disease conditions （59.6%）, un-timeliness at recording and writing （43.6%）, and inconsistency in doctors＇ and nurses＇ records （28.6%）. Conclusion Transformation of views, enhanced nurse-doctor cooperation, performance of class management of clinical nurses and use of nursing record forms are key for reducing the problems in nursing report writing.